Endoscopic Submucosal Dissection (ESD) is the gold standard for large colorectal neoplasms but is hampered by technical complexity and prolonged procedural times. A primary inefficiency is the repetitive instrument exchange required to manage intraprocedural bleeding. Standard protocols dictate switching from a dissection knife to hemostatic forceps (e.g., Coagrasper) upon encountering vessels, a cycle that disrupts the surgical plane, increases cognitive load, and significantly raises procedural costs. Furthermore, precise settings for the ESG-300® (Olympus®) generator in certain situations in advanced endoscopy are lacking in comparison to other brands like the VIO3® generator (ERBE®).

We introduce the "ONE-PEDAL-DRIVING ESD" concept. Analogous to electric vehicles (EVs) where a single pedal controls both acceleration and regenerative braking—enhancing efficiency and reducing wear—this technique utilizes a single electrosurgical setting (PowerCoag E2 30W) and a single instrument (DualKnife J®, Olympus) for the entire submucosal phase. The innovation lies in hydro-modulation: leveraging the physics of electrosurgery where saline immersion drops impedance by 99% (Capogreco et al., Sci Rep 2025). By altering the environment from CO2 (higher cutting effect) to static saline (moderate cutting effect) or active saline infusion (high coagulation effect due to electrodispersion), the operator achieves diverse tissue effects without modifying the generator settings or changing instruments.

The video demonstrates the resection of a 50mm bulky sessile lesion (JNET 2A) in the mid-rectum, characterized by thick penetrating arterial vessels. Using the ESG-300 on PowerCoag E2 30W, the procedure was completed in 55 minutes with zero instrument exchanges.

1. High-Speed Dissection: Under CO2, high voltage allows agile cutting of submucosal tissue with no or small vessels.

2. Moderate-Speed Dissection: Submerging the submucosal plane in saline utilizes the voltage drop to seal small-to-medium vessels with a low spark.

3. Hemostasis: Active saline infusion during activation created an electrodispersion effect, mimicking soft coagulation for large bleeders or vessel sealing. The technique eliminates the need for hemostatic forceps, reducing cost and maintaining surgical flow.

"One-Pedal-Driving ESD" transforms the ESG-300 and DualKnife J into a high-performance all-in-one solution for ESD. By understanding and manipulating the electrophysical behavior of the PowerCoag waveform in different media, endoscopists can eliminate the hemostatic forceps, reducing procedural time, cost, CO2 emissions and complexity while mimicking the efficiency of modern EV operation.